Access Remains an Issue for Women Worldwide Seeking Abortion

Lack of providers, facilities are difficult barriers to overcome

Action Points

Women in developed countries seeking first-trimester abortions face serious issues of accessibility to appropriately trained clinicians, appropriate equipment and medication, and timely access to services, according to a systematic review.

Uptake of medical aborton has been low, and lack of training is cited frequently.

Women in developed countries around the world still face serious accessibility issues when it comes to first-trimester abortion, including access to appropriately trained clinicians, appropriate equipment and medication, and timely access to services, a systematic review found.

Frances Doran, PhD and Susan Nancarrow, PhD, both of Southern Cross University in Lismore, Australia, reviewed 38 studies about the barriers and facilitators to women accessing first-trimester abortions in developed nations.

"Despite fewer legal constraints than in the developing world, women and service providers in developed countries face barriers in relation to provision of abortion services and their lack of access to them," they wrote, summarizing their findings in the Journal of Family Planning and Reproductive Health Care.

Two-thirds of the examined studies were quantitative with data from the U.S. included in 22, covering periods from 1993 to 2014. The review was structured to address a number of World Health Organization guidelines about access to safe abortion services. Other countries with data included in the review were Australia, New Zealand, Canada, the U.K, Norway, Sweden, and France.

Lack of training was a common refrain among the studies examining medical abortion. Two studies found that around a quarter of advanced clinicians were interested in receiving training for medical abortion, but were concerned about "inadequate backup access to aspiration services." Healthcare staff such as nurse practitioners, physician assistants, and certified nurse midwives wanted to offer medical abortion services, but cited lack of training -- along with legal issues such as increased malpractice insurance -- as potential barriers.

The six studies examining medical abortion reported the decline of services at hospitals and doctors' offices, along with the corresponding increase in "nonspecialized" freestanding clinics. There was also a 23% increase in medical abortion at these clinics, and a 9% and 13% decline in the number of hospitals and physicians' offices, respectively.

But the authors found that medical abortion is only a small percentage of total abortion procedures. Medical abortion comprised only 15% of Canada's abortion procedures, with only 13% of U.S. facilities offering the service. Nancarrow told MedPage Today via e-mail that she was surprised at the relatively low uptake of medical abortion, even in these developed countries.

Reduced patient travel and fewer cancellations due to travel and weather

Greater appointment availability and location

Increase in medical abortions and abortions before 13 weeks gestation

Decline in overall abortion rate

Nancarrow said that she was the most surprised by the fact that medical abortion could be administered using the telehealth model, and saw potential for it to increase access for women living in rural and remote areas.

"The potential for telehealth services to deliver abortion is an exciting opportunity which can increase service accessibility for marginalized women, as long as it is seen within a comprehensive health governance framework," she said.

Limitations noted by the authors include the fact that the studies examined were restricted to a more homogeneous population in developed, English-speaking countries. This limits its generalizability to the global population. In addition, the majority of studies were descriptive surveys, not randomized trials.

Nancarrow concluded that future funding models need to reflect the narrow window in which women can access abortion services and said that she would like to see more explicit exploration of good models of care to support them.

"It seems that abortion services are seen as slightly marginalized services that do not get the same priority as other elective procedures -- this is probably due to the social/political stigma around them," she said. "However they need to be treated equally with other services to ensure that issues to do with safety, accessibility, quality (including best practice) are not overlooked."

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